Clinical relevance of combined treatment with exercise in patients with chronic low back pain

Key points

1. 01Exercise plus manual therapy produced the greatest ODI disability reductions at 3 weeks (54.7%) versus exercise alone (27.1%) or exercise plus kinesiotape (19.9%).
2. 02The manual therapy group reached a clinically significant ODI cutoff (-54.71% at 3 weeks, -63.16% at 6 weeks, -87.70% at 12 weeks).
3. 03All three groups improved significantly across all outcomes at 12 weeks, suggesting core exercise is the common driver of benefit.
4. 04Kinesiotape combined with exercise showed the weakest disability improvements and did not outperform exercise alone.
5. 05No significant between-group differences were found for kinesiophobia, catastrophizing, self-efficacy, or pain pressure thresholds at any time point.

How it was conducted

Design

Single-blind 12-week randomized controlled trial (RCT); NCT05544890

Participants

55 enrolled (48 completed); adults 18-65 years with CLBP and mild disability (ODI < 20%)

Groups

(1) Core exercise alone (ET, n=19); (2) Spinal manipulation + core exercise (ETmanualtherapy, n=18); (3) Kinesiotape + core exercise (ETkinesiotape, n=18)

Intervention

24 sessions over 12 weeks, twice weekly; core stabilization exercises in all groups; manual therapy or kinesiotape added before exercise in respective groups

Primary outcome

Disability via Oswestry Disability Index (ODI)

Secondary outcomes

Pain pressure thresholds (PPTs), kinesiophobia (TSK), catastrophizing (PCS), and self-efficacy; assessed at baseline, 3, 6, and 12 weeks

What they found

• ODI Group x Time interaction: F[4.09, 87.99] = 9.54, p < 0.001, partial eta-squared = 0.048
• ETmanualtherapy vs. ET at 3 weeks: MD = -0.057, 95% CI -0.096 to -0.018, p < 0.001
• ETmanualtherapy vs. ETkinesiotape at 3 weeks: MD = -0.047, 95% CI -0.086 to -0.008, p = 0.005
• ETmanualtherapy vs. ETkinesiotape at 6 weeks: MD = -0.039, 95% CI -0.078 to -2.715, p = 0.046
• ETmanualtherapy vs. ETkinesiotape at 12 weeks: MD = -0.040, 95% CI -0.079 to -7.57, p = 0.040
• ODI delta at 3 weeks: ETmanualtherapy -54.7%, ET -27.1%, ETkinesiotape -19.9%
• ODI delta at 12 weeks: ETmanualtherapy -87.70%
• TSK Group x Time interaction: F[1.73, 76.22] = 3.72, p = 0.034; no significant between-group post hoc differences
• PCS Group x Time interaction: F[3.45, 75.94] = 5.61, p < 0.001; no significant between-group post hoc differences
• Self-efficacy Group x Time interaction: F[3.61, 79.45] = 2.08, p = 0.097; no significant between-group differences
• PPT Group x Time interaction: F[3.55, 78.18] = 1.79, p = 0.146; no significant between-group differences
• Dropout rate approximately 15% (7 of 55 participants)

Limitations

• Small sample size (48 completers) limits generalizability and statistical power for secondary outcomes.
• Single-blind design only; participants could not be blinded to treatment allocation, introducing performance and expectation bias.
• Study restricted to patients with mild disability (ODI < 20%), so findings may not apply to those with moderate or severe CLBP.
• Baseline PCS scores differed significantly between groups, which may have confounded catastrophizing outcomes.

Why it matters

For patients

If you have mild chronic low back pain, doing core exercises is likely to help, and adding spinal manipulation sessions beforehand may speed up improvements in daily function in the first few weeks.

For clinicians

Manual therapy prior to core stabilization exercise produces faster, clinically meaningful disability reductions at 3 weeks compared to exercise alone or kinesiotape; however, by 6-12 weeks all approaches converge, so the main advantage is an earlier onset of functional gains.

For readers

This RCT supports multimodal care combining manual therapy and exercise for CLBP, but the benefit over exercise alone is largely confined to disability in the short term and does not extend to pain sensitivity or psychosocial outcomes.